Did I do the wrong thing? Advice needed. (Long)

Hi all. I'm a new grad, and have been working on a medical oncology floor for about a month now. Our floor gets anyone who has a medical issue, as long as they were diagnosed with cancer at one point or another in their past.

Recently I was on a night shift. The hospital I'm at does obs at about 8pm, then policy is not to do any more until 6am. I have some reservations about this, because a lot of these people are not all that well, and I would like to know about any potential problems more than an hour before I am due to go home.

That said, I took obs on one guy. Old, about 78, hx lung cancer, admitted with SOB. O2 @ 2L via NPs. Obs at 8pm fine, no problems. He slept well all night, observed to be settled on all rounds, O2 in situ.

By 6am, his heart rate was 161 and his BP was 98/64. He had a low BP historically, but this was a little bit lower than usual. I knew he had a history of AF, and was on digoxin. He didn't feel dizzy, sick, hot, cold or anything unusual; in fact, he felt fine and wanted to stand up for a shower. I asked him not to stand up until I came back. Because I am new and still quite unsure about my judgement skills, I checked with my mentor. She basically said "If you think he's OK, then he is, it's not unusual for AF pts to have HRs that high". She' an awesome nurse, she knows EVERYTHING (or so it seems!). Fair enough, thought I.

I found out today that the oncoming shift decided to make a MET call (rapid response team/Medical Emergency Team) call on him. The team just gave him some MgSO4 and trundled off again, so he was fine.

But... and here's the point... do you think I should have called a MET myself? Our criteria say you can call a MET for a pulse >140. I didn't feel it was warranted. Did I miss a GIANT red flag? Could this guy have died if the next shift didn't make the call? I'm looking up stuff about AF now to see if I can find some info about appropriate management, but I want your opinions, too.

I would have at least called the doc. If the guy was not previously in a-fib and spont. coverted into it, at a rate of 160, that is wayyy to fast. They would want to try to slow that rate down at least. Alot of times, they cant hold their pressure very well, and he could have detiorated more. The heart does not like to have to beat that fast for long periods of time. So yeah, I think you should have definately called the doc. A rate of 120, not so bad, but 160 is high.

Cher

Mar 6, '07

Heart rates in the 160's are way too fast, even for patients who are chronic afibers. Without telemetry you had no way of knowing whether this was uncontrolled afib, svt or vt. Some patients can have sustained runs of perfusing vt that last for quite a while, and be completely non-symptomatic. You mention that the pt had a hx of lung ca, but didnt mention the reason for the admission. Some patients can have ST that high when they are septic. All in all I would have probably called the rapid response, at the very least called the doc. With a rate that high I would have wanted him on a tele unit where they could keep a closer watch on what was going on with his heart, and where they could take more aggressive steps to keep his rate under control.

Mar 6, '07

Sorry, I just read your post again and saw that he was admitted with SOB. He could still be septic, but nontheless, even though afibers can have rates that high does not mean that it is good for them to have rates that high.

Mar 6, '07

Have to agree, I'd have called the doc, if only to get him on tele so I could watch what he was doing.

Of course, I'm in ER and I'm spoiled in that if we think someone needs tele in the ER, we stick 'em on the monitor LOL. To the point where I want everyone on tele just so's I can be sure!

Mar 6, '07

Okay, perspective from another new grad here. *grin* I've been working on a surgical tele floor since June.

The HR was definitely way too high, and without tele monitoring or an EKG, you have no way of knowing which rhythm he was actually in. Even were he in AFib, a doctor would have most likely put him on a med to control the HR.

That being said. Please don't beat yourself up too much. You're new at this. You thought something might be wonky, you approached your mentor, letting her know that you thought something might be wonky. With you level of experience (or lack thereof) I feel your mentor should probably have taken a look at the patient herself or else encouraged you to call the doctor/rapid response, etc.

You are new at this, you aren't going to know everything, and it's okay to ask more experienced nurses questions. If you've only been on your floor for a month, are you even off orientation yet? I felt so fortunate that my orientation lasted 12 weeks, and I still go to my charge nurse questions when I see something I'm not sure about.

Heart rates in the 160's are way too fast, Some patients can have sustained runs of perfusing vt that last for quite a while, and be completely non-symptomatic. .

I have seen this before (idiopathic V tach) It's the craziest thing. Bottom line, at the least the dr should have been called and I would have been in a panic to see an EKG, or at least place him on tele to see whats doing.

It is a learning experience and pt did not die. So now you know, and next time you will be more quick about responding appropriately.

Mar 6, '07

Were your 6 a.m. vitals rechecked manually? AF patients are notorious for giving false readings on automatic machines. I probably would've gotten an EKG, called the doc with those findings and then asked him for a Tele because the patient has a Hx of AF. AF patients can run high HR, usually in the upper 120's, but anything above 130'ish starts to cause some issues after awhile.

All is fine with your patient, so don't beat yourself up. If possible, talk to the day shift nurses that called the rapid response team and find out why they did it. Ask questions, learn from this experience so that you get an understanding of the process and why they called. Maybe sit down your your preceptor and talk about why she didn't feel the need to intervene. Talk, talk and then ask, ask LOTS of questions about this incident because it's a great learning exprience for you!!!

Mar 6, '07

O.K.
Yes. The pt was in rapid rythm w/hx of AF.... that's immediately a flag for the more experienced cardiac nurses (and many non-cardiac as well).

However, the OP states the pt was essentially asymptomatic...maybe this guy lives there when at home...we don't know and the OP doesn't know.

Yes. The doc should have been called and the pt should have been put on tele to determine exactly what was presenting.

However, this is an oncology floor dealing with a myriad of bodily mess-ups related to hx of cancer. Our bodies can do weird things after being exposed to disease and treatment. We (meaning those not working on oncology) don't know what is seen often on that floor and considered "norm". If people saw the cardiac output/index that we are ok with in CVICU, most would absolutely freak out because they don't live it.

To the OP: DON'T beat yourself up over this one. Yes, you had a gut instinct, but you accepted that you are still new at this so you asked an experienced nurse. You had no reason to go against what she said. Most of us would do the same thing in your shoes. As far as you not calling RRT on your shift....in a perfect world, it didn't seem you needed to. The pt was asymptomatic and it is drilled into new nurses to "treat the patient, not the numbers". If you were able to note a downward trend, I am sure you would have called them.

That said, you will, however, need to keep up with hospital protocol. There are many things all of us do at work that seems over-the-top or just plain unnecessary because they are protocol, but most protocols are put into place because of a negative event. Following it can CYA in bad times.

All-in-all, this was a stressful experience for you. It was also a wonderful learning experience at the same time. Believe me when I say, the knowledge that sticks the tighest in most nurses minds is that which was learned from a bad experience. Now you know how to handle that type of situation and will probably never forget it.

*breathe*

Mar 6, '07

I agree that the man was having a problem, but at least you came to someone with more experience and asked for help/advice. It's a learning experience, just take it for what it is.

As a new grad 2 months into nursing, I had a patient who was having problems and I was the only one out of a team of 2 MDs and 3 nurses, who felt the patient was not taken care of. The patient was had a brain bleed and subsequently died in Hospice. So,,follow your instincts I would say.

Don't let this experience discourage you.

Love, Natasha

Mar 6, '07

Always go with your gut feeling. No matter what a mentor says, if you have abnormal VS, even if the pt says he's feeling well, you need to report abnormal VS. If only to cover yourself. What if your pt had gone bad? Someone would say, "How come you didn't report the abnormal VS" and you would not get by with saying your mentor told you not to report and the pt said he was ok. You are the professional nurse, believe it or not, officially out of orientation, I take it, and responsible for a full workload. It's you they will come after if you mess up.

So just always protect yourself and, in the process, you will be protecting the pt, the employer, even the doctor.

We've all goofed up, don't let this stop you or discourage you. You are wise to post-mortem it. I, too, would like to know why EMS was called and not just MD notified.

And what does "obs" mean? Observation? Obstetricians?

Mar 6, '07

Yes, you should have notified the doc.......HOWEVER, I don't think you did anything "wrong". You kept an eye on him and you checked with someone with more experience. You didn't blow it off and ignore him. Use this as a learning opportunity and move on.

{{{Beth}}}

Mar 7, '07

Thanks, everyone. I had come to the conclusion that I did make a mistake not calling the rapid response team after I did some research, but I really appreciate your input and experience. Next time I see something funny I will definitely call the docs - I'd rather look stupid for worrying too much than too little.

In answer to some questions, I am only 5 weeks into my new grad year. I am 'off orientation' officially; I got three WHOLE days as official orientation, but I am part of a new grad program whereby everyone knows I am a new grad and so are willing to help out if I have problems, questions or skills I am not allowed to perform without accreditation from the facility (inserting IVs, doing PICC dressings, accessing or de-accessing portacaths etc - I'm in Australia, we do things a little bit differently to you guys. I think you have a better system in many ways for training nurses.) I do take my own patient load, and that night I had eight. I did verify those obs (errr..... vitals? Is that what you call them?) manually, because my BP machine is dodgy at the best of times, and I know that our pulse oximeter doesn't handle odd rhythms well.

I am trying not to beat myself up; what happened, happened, and I (and my patient!) was lucky that nothing serious went wrong. I feel stupid, in retrospect, that I even had to ask about this. I am DEFINITELY learning from my mistake. Anyone whose heart rate is unusual to me will be getting at least a call to their doctor.

Thanks for being so supportive to me, everyone. I am so glad there's a place I can come to ask experienced nurses questions like this without fear of embarrassment!